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Spring 2016 Trauma and Recovery in Post-Conflict Northern Uganda: An analysis of Trauma and its effects on the Family Shelby Logan SIT Graduate Institute - Study Abroad
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Recommended Citation Logan, Shelby, "Trauma and Recovery in Post-Conflict Northern Uganda: An analysis of Trauma and its effects on the Family" (2016). Independent Study Project (ISP) Collection. 2344. https://digitalcollections.sit.edu/isp_collection/2344
This Unpublished Paper is brought to you for free and open access by the SIT Study Abroad at SIT Digital Collections. It has been accepted for inclusion in Independent Study Project (ISP) Collection by an authorized administrator of SIT Digital Collections. For more information, please contact [email protected]. Logan 1
“Trauma and Recovery in Post-Conflict Northern Uganda: An analysis of Trauma and its effects on the Family” Shelby Logan School for International Training Advisor: Dr. Kitara David Lagoro Academic Director: Martha Nalubega Wandera Gulu Spring 2016
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I would like this to be dedicated to the late Akena Fred David. Your passion and care for your students is the reason I pursued this topic further and I am regretfully sorry that you did not get to see your ideas come to fruition. Thank you for your contribution to this paper, Kitgum lost a great educator.
This research is also dedicated to all of those that have silently suffered because of the atrocities they experienced, your stories were heard and will never be forgotten.
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Acknowledgements There are so many people to thank for supporting me in this endeavor. First, I must thank my parents for allowing their daughter to fly across the world to a wonderful place like Gulu, Uganda. Thank you for always supporting every dream I have ever had or cause that I have advocated for. This trip would not have been possible without your love and support and for that I am forever grateful. To my fellow SIT students, thank you for being the most wonderful bunch of people I have had the pleasure to be a part of. This experience would not have been so amazing without the friendships that were made and the memories that I will never forget. I am actually sad that we do not get any more time in the van together after this week. I wish you all the best of luck with the rest of your endeavors. To Tim Reese, there are no words to express the amount of gratitude I have for the support that you offered during this entire semester. Thank you for always picking up the phone, for editing documents in the middle of the night, and for making me feel sane even when the world felt like it was collapsing. You are the best kind of person and I am so grateful for you in my life. To the SIT Staff, thank you for answering every stupid question I have ever had, for making sure I did not die in Africa and for showing so much support for your students. These research initiatives could never have come to the fruition that they have without your guidance and passion for your students. Leonard, thank you for always pushing me to move with confidence and never letting me doubt myself or my ability. Martha, thank you for being an ear to listen whenever I needed anything. I am forever grateful for your support during this semester and I will miss you terribly. Simon and Meddie, thank you for doing absolutely everything and anything for us during this research period. I could not have done it without you. Gulu you have changed my life and for that I am forever in your debt. Thank you for accepting me into your lives and teaching me more than I could ever imagine.
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Abstract Trauma in Northern Uganda stems from the atrocities that occurred during the Lord’s Resistance Army conflict. Because of this, thousands of victims were left traumatized by their experiences with disparities in aid to help them with their trauma. Utilizing the rural and urban areas in Kitgum and Gulu Municipality, this research seeks to understand how trauma presents itself in the Northern Uganda region and how it is defined by the population who treat it. This includes a list of disorders resulting from trauma and their symptoms. In addition, the efforts towards trauma healing and recovery are analyzed, including the different forms of treatment and how they affect the population. In this section, these forms are criticized and analyzed with their given challenges. With these challenges, the research takes an in-depth look at how trauma affects the family unit and what it means for Northern Uganda to develop a “trickling trauma” problem. Lastly, recommendations are given to try to mitigate the challenges that face trauma treatment today in Northern Uganda. This qualitative research was conducted over the course of a month. During this time, interviews and focus groups were utilized in an attempt to better understand the topic of trauma in northern Uganda. These interviews were conducted amongst a population of NGO workers, local government, medical staff, and victims of trauma themselves. These respondents were specifically targeted for their relevance to trauma and its treatment. By snowball sampling, key informants were identified and then those key informants recommended other respondents that would aid in the researching of this topic. Each interview was recorded by taking notes and/or recorded by voice recorder with the consent of each respondent. It was found that depression, anxiety, paranoia, and post-traumatic stress disorder were the most prevalent of the disorders that stem from trauma. Through these disorders many different demographics of people are affected and come are interconnected in the family unit. This means that a father’s PTSD may result in gender-based violence which then traumatizes both the mother and the child, thus creating a new generation of trauma that was not directly affected by the war. Efforts towards treating these disorders range from psychosocial support, counseling, and medication prescriptions, each of these come with their own criticisms and recommendations are given in order to aid in mitigating the challenges they face.
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Table of Contents Acknowledgements…………………………………………………………………3 Abstract……………………………………………………………………………..4 Maps………………………………………………………………………………..6 Acronyms/Definitions……………………………………………………………...7 Chapter One: Introduction…………………………………………………………8 1.1 Introduction……………………………………………………………8 1.2 Background……………………………………………………………9 1.3 Problem Statement……………………………………………………11 1.4 Objectives of the Study……………………………………………….11 1.5 Scope of the Study……………………………………………………12 1.6 Significance of the Study……………………………………………..12 Chapter Two: Literature Review…………………………………………………13 Chapter Three: Research Methodology…………………………………………..18 3.1 Introduction to Research Methodology………………………………18 3.2 Research Design……………………………………………………...18 3.3 Area of Study………………………………………………………....19 3.4 Study Population……………………………………………………..19 3.5 Sampling Procedure………………………………………………….19 3.6 Sample Size…………………………………………………………..20 3.7 Data Collection Methods…………………………………………….20 3.8 Data Analysis………………………………………………………...21 3.9 Limitations of the Study……………………………………………..21 3.10 Ethical Considerations………………...... 22 Chapter Four: Findings and Analysis…………………………………………... 24 Chapter Five: Conclusion………………………………………………………..51 Reference List……………………………………………………………………53 Appendices………………………………………………………………………55 i. LRA Conflict Timeline……………………………………………….55 ii. Preliminary Question Guide………………………………………….58 iii. Uganda National Council for Science and Technology Permit……..59 Logan 6
Regions of Study Maps
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List of Acronyms CBO – Community Based Organization CVT – Center for Victims of Trauma DHO – District Health Officer GBV – Gender-Based Violence ICRC – International Committee of the Red Cross IDP – Internally Displaced Persons KICWA – Kitgum Concerned Women’s Association LAG – Live Again LRA – Lord’s Resistance Army MHFP – Mental Health Focal Person NGO – Non-Governmental Organization NRA – National Resistance Army PTSD – Post-Traumatic Stress Disorder RLP – Refugee Law Project TPO – Transcultural Psychosocial Organization UNICEF – The United Nations International Children’s Emergency Fund UNHCR – United Nations High Commissioner for Refugees UPDF – Uganda People’s Defense Force WHO – World Health Organization
Definitions Trauma – In this work, trauma is defined as a subset of mental health. It is a category of mental health when a victim experiences an atrocity like experience that causes them discomfort and disorder after the event occurred (e.g. death or torture)
Mental Health – In this work, mental health is defined as the general well-being of one’s mental state.
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Chapter One: Introduction
1.1 Introduction The conflict in Northern Uganda left whole regions devastated by visceral traumatic experiences and citizens left to handle those feelings on their own. There were Non-Government Organizations (NGO) that came in but the extent of their reach was not large enough. They chose one demographic to tackle which took care of the formerly abducted but left out the rest of the population in the North. The research, to be conducted over the next month in the northern region of Uganda, seeks to further understand the effects of conflict on the north. In specific, the area of study will be trauma within mental health and its effects on the post-conflict communities. It seeks to answer the question, to what extent does trauma and its recovery effect the interconnected dynamics of family life and what support exists in order to mitigate this issue? In order to gain in-depth knowledge of this topics, a partnership was formed with Mental Health Uganda that is stationed within the Gulu Referral Hospital. This Community Based Organization(CBO) seeks to offer psychosocial support, education, and counseling to those suffering from trauma and other mental health disorders that stem from traumatization or grief. They offer the resources needed in order to understand the different aspects of mental health and the way it functions in the Northern Ugandan Region. The issue at hand for those who suffered trauma from the LRA conflict is that many lost family members, witnessed atrocities, and/or found themselves abducted by the Lord’s Resistance Army (LRA). That being said, 85 percent of the LRA were made up of young children which is cause for concern in general. However, their trauma did not end in that moment. They are experiencing lasting effects and symptoms from traumatic experiences that continue to haunt them today and because of this, it now haunts the next generation of children. In order to investigate this problem, the issues were looked at in the context of families and the different ways that trauma effects each demographic (Man, Wife, and Child). This was in the location context of Kitgum and Gulu which provides adequate coverage of two districts largely affected by the conflict; one rural and one urban. The study addresses the lack of resources and services that continue to persist even ten years after the conflict. Research conducted in the past has investigated what treatment is needed for those suffering from mental health disorders but these treatment options are not available nor efficiently dispersed. Through preliminary research, the gap that presented itself was also the Logan 9 diagnosing of Post-Traumatic Stress Disorder (PTSD) and how the recognition of symptoms can leave some victims without diagnosis, leaving them without treatment. Preliminary research has shown that Post-Traumatic Stress Disorder (PTSD) is not being diagnosed and as a result treatment is unavailable. In large part, this is due to symptoms not being recognized or attributed to PTSD.
1.2 Background
Background on the Conflict In 1986, Yoweri Museveni, leader of the National Resistance Army (NRA), overthrows President Milton Obote and appoints himself president of Uganda. At the same time, Alice Lakwena (An Acholi from the North) creates the rebel group, the Holy Spirit Mobile Forces, a rebel group Christian “spirits” ordered her to create. These two events fueled chaos and targeting of the North in a way that would make it possible for Joseph Kony to take over. In 1988, Kony creates the Lord’s Resistance Army (LRA) from Lawkena’s left over forces. The LRA and UPDF soldiers fought a violent war for 20 years that left families with broken homes and poor economic situations. Their family members were abducted; men, women, and children utilized in heinous crimes against humanity. Because of these incidents, the citizens of Acholiland were affected physically and some times more importantly, mentally. For a detailed timeline of events, see the appendices.
Background on Mental Trauma Mental trauma is an unfortunate consequence of conflict no matter the circumstances in which it is created. Specifically, the LRA conflict that tore through the Northern Ugandan region affected a wide range of Acholi people. It caused stress, anxiety, and extreme traumatization. With these mental health effects, school dropout rates and suicide have climbed amongst the youth population in recent years and are beginning to cause an entire generation to inadequately live by the standards set by their learning institutions and their home communities (Emilio Ovuga, 2013). These issues not only arise within the youth, but also are a major debilitating factor in everyday life for the adult generation, impacting job efficiency and quality of life Logan 10 amongst their family members. Up to thirty percent of adults experience high levels of psychosocial and psychiatric morbidity (Emilio Ovuga, 2013). The primary issue is that resources are very scarce for those suffering from mental health disorders. For example, 87 percent of the population live in rural areas where access to health services for their mental health needs is only twenty percent have access to health services for their mental health needs (Emilio Ovuga, 2013). There is an escalation in mental health cases because of the lack of diagnosis. This means that symptoms existing in others (that are going untreated) and affecting others in the community, creating an escalation in cases. For example, a father with severe trauma may affect his home by participating in gender based violence which then affects the child of the two parents because of the violent nature that the father displays that the child is viewing. Therefore, trauma from those that lived through the conflict period are effectively creating a new generation of trauma victims. This is where the research is lacking. It is necessary to combat the formerly abducted centered research to look deeper at the effects of trauma as a whole.
Background on the Organization
Mental Health Uganda is a CBO that focuses on psychosocial support as well as medicinal support through the Gulu Referral Hospital. In addition to their mental health support, they work on developing communities that they are integrated into. Programs like “Pass-a-Goat” focus on dispersing livestock to each member of the support group so that those goats can then produce and be given to help another family. They are a support for not only victims of trauma but also victims of many other aspects of mental health including, gender based violence, PTSD, and protection of those suffering from depression. Their missions are to support and work with local communities, civil society organizations and local governments to meet the social protection, psychosocial and mental health needs of vulnerable people. Even though this organization is young, it holds goals for the future to develop into the northern regions of Kitgum. The organization also work with health care workers to build their capacity of knowledge of diagnostics and what certain mental health disorders look like, how mental health disorders present themselves and how they can be treated. This can include counseling or medicinal Logan 11 prescriptions. It is a strengthening tool for communities who are not developed enough to handle the traumatized victims that reside there.
1.3 Problem Statement The problem in the Northern Ugandan region regarding mental health and the access to mental health care is paramount due to the growing rate of complications that stem from the lack of diagnosis or awareness of mental health disorders and their side effects. These issues perpetuate an atmosphere of suspended life because of the setbacks and symptoms of someone suffering from PTSD, Depression, or Anxiety related to their trauma. This topic merits investigation because of the obvious gap in trauma victims and resources available to these victims. Research does not cover the population that was left after the abductions takes place and it is the goal of the researcher to expand on this area of study. When preliminary research was done in the Kitgum district, it became clear that there was serious lack of resources available to those in need in the rural areas. This research is crucial in order to seek out why those gaps exist and how this gap is affecting the community and its interconnecting demographics (e.g. family life). The family focus is important because the effects of trauma on members of the family is generating a new generation of disturbed persons who are affected by the trauma of their elders.
1.4 Objectives of the Study Analyze the different forms of trauma resulting from the LRA conflict. Analyze the efforts towards trauma treatment and understand the ways it is treated. Examine the effects of trauma on mental health in the family unit in Kitgum and Gulu. Propose ways in which trauma treatment challenges could be overcome.
1.5 Scope of the Study
Geographical Scope The geographical scope of the research took place in Kitgum and Gulu districts. Within these places, NGO offices, villages, and government offices/health facilities were visited to perform adequate research.
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Content Scope The scope of content ranged from identifying the types of mental health disorders that exist in the post-conflict Northern region to researching how the gaps in diagnosis and treatment can be mitigated and for what reason they exist. This was conducted through studying the dynamics of families and how each member of the family is affected by trauma and mental health. Because of these issues, it was sought to find the gaps in the research for trauma affected victims and their families in something that is referred to as “trickling” trauma. Pertinent research was found to be obtainable and many respondents described the content that was utilized to directly approach this topic and exacerbate all possible forms that this idea takes root in.
Time Scope The research was conducted starting February 20, 2016 and ended May 3, 2016. Two weeks were dedicated to traveling to Kitgum while the remaining time was spent in the Gulu Municipality.
1.6 Significance of the Study This research is significant because of the growing problem of untreated mental health patients that exist in northern Uganda because of the atrocities that occurred during the LRA conflict period. The beneficiaries of this research are foremost the victims of trauma because this research seeks to bridge the gaps that exist between victims and resources to help them. Hopefully, when this research is finished there will be new information found on these topics and can be used to improve the current trauma treatment system. The current system could benefit from this research to understand the gravity of the problem. The problem is an ever-growing issue with suicide rates climbing and PTSD causing gender based violence (GBV); all connected to mental health and traumatic experiences. This is why this research is important and needs to bring about change to the different aspects of this topic area.
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Chapter Two: Literature Review In order to gain preliminary knowledge on the topic of mental health and trauma, it is important to understand how these different disorders are defined and how they play into the post-conflict situation in Northern Uganda. Post-traumatic stress disorder (PTSD) is a mental disorder that may develop after exposure to atrocities and life-threatening events (Bisson, Jonathan, 2015). It can happen from one event that was especially traumatic or from prolonged exposure to trauma (Besson, 2015). Additionally, it can be described as a psychiatric condition which develops after a person experiences, witnesses, is confronted with or hears about emotionally stressful and painful experiences beyond what a human being can bear (Ovuga, 2012.). It is also one of the prevalent disorders that people who lived during the time of the LRA war have experienced. In some cases, this disorder has gone undiagnosed. Because of the long term exposure to human rights abuses in Acholiland, the symptoms often present themselves without the victim knowing what they are experiencing or how it results of their traumatization. This is due to the fact that ninety percent of the population of the North were displaced and in danger of LRA forces raiding and causing mass atrocity in their homestead (Ovuga, 2014). Because of the human rights abuses that occurred, many of the citizens witnessed events that were and are very harmful to their mental health which had immediate and delayed effects on their lives. These symptoms can include mood swings, nightmares, flashbacks, and isolation (Besson, 2015). Unfortunately, due to the lack of knowledge about mental health, many cases in Northern Uganda go undiagnosed and medically untreated. Mental health is inevitably linked to trauma through the atrocities that occur and the PTSD that follows. In the case of Uganda, the north suffered greatly from the Lord’s Resistance Army’s terrorization of Acholiland. It is an international concern as well as a national concern due to its disruption to social, interpersonal, academic and work functioning (Nakimuli-Mpungu, Etheldreda, 2013). Through research, Northern Uganda was found to contain a high prevalence of both depression and post-traumatic stress symptoms (Nakimuli, 2013). For example, 85 percent of the LRA was made up of children (Ovuga, 2014). This means that thousands of children from Acholiland suffered from captivity in which they were tortured, injured, sexually assaulted or raped, involved in combat, witnessed horrendous atrocities, and were used as porters and human shields (Ovuga, 2014). Therefore, the level of PTSD, depression and emotional and behavioral problems that were found in the formerly abducted were extremely escalated. Logan 14
Studies have shown that 90 percent of the population surveyed were said to have witnessed a shooting and more than half had admitted to having killed someone (Ovuga and Larroque, 2012). In addition to those that were abducted, those that were forced into Internally Displaced People (IDP) camps by the government were exposed to highly traumatizing events for over two decades dealing with mutilation, abduction, and mass murder (Ovuga and Larroque, 2012). These traumatic events not only caused PTSD and other symptoms of depressions and anxiety but they also caused many social issues for citizens of the north. The children of former female abductees who returned from the bush war are often not accepted. This leads to lack of education, poverty, early marriages especially among female children, family breakup, and the disempowerment of men as heads of the household (Ovuga and Larroque, 2012.) These factors are the connections in which cause trickling trauma. This is the case affecting families with mental health issues especially linked to trauma. Additionally, it is also where the research ends on trauma’s effect on the family but does not mitigate the importance of the issues and is the reason for the research being done in this initiative. However, it is no question that long term exposure to war is a known factor for long-term mental health problems and psychosocial distress. A gap is formed between resources and access to these resources for those that live in more rural areas. It was found that within the Ugandan health system, there was an absence of any mental health staff until Health Center Four. In this center only one psychiatric nurse that was posted at this site (Bainjana and Mangen, 2011). When understanding the health center scale, General Hospitals have one psychiatrist and one regular psychiatric nurse and in the Regional Referral Hospital has one psychiatrist, one clinical psychologist, and one regular psychiatric nurse (Baingana and Mangen, 2011). Health Centers begin with the lowest form of respondent which is Village Health Team and move from one up to the Hospitals. Unfortunately, this is a problem which was found during the research period and will be discussed in the findings. Briefly, there is a lack of ability for transportation for people to access the Health Center IV or higher healthcare because of time challenges and work schedules and the expensive travel fees involved. This is the reason for such high levels of undiagnosed trauma disorders. In order to attempt to mitigate these high levels, the Peter C. Alderman Foundation (PCAF) initiated a partnership to create trauma clinics in four districts in the region (Nakimuli, 2013). Through this initiative, “the partnership has endeavored to provide routine psychological Logan 15 treatments to individuals initiating care in the trauma clinics (Nakimuli, 2013).” These initiatives are supposed to be in place consistently throughout the region to the effect that free services should be offered to anyone who suffers from PTSD. However, a disconnect remains between what is supposed to available and what is actually available. In addition, TPO Uganda helped with medicine supply and staffing and had made a deal with the government hospitals that they would offer their maximum in the beginning with a slow decrease over time in order to aid the hospitals in becoming self-sufficient. However, the government failed to cover their end of the agreement and suddenly medicine and staffing became a huge issue when TPO was ready to exit the health care system (Baingana and Mangen, 2011). It was found that during this time, refresher training was not provided for health workers and so knowledge and skills of those who remained in the project became outdated and a decrease in personnel and knowledge within the hospital system developed. This explains the current lack of staffing within the hospitals. The access to resources is a huge problem for those suffering from any type of mental illness. For the purpose of this research, the focus on trauma counseling and treatment is the focus of this review. Studies shows that a small number over fifty-percent were able to access some form of rehabilitation services, however, most of these people are participating in traditional cleansing ceremonies not including professional counseling services in addition to their cultural practices (Muldoon, Katherine, 2014). Those who receive counseling services rarely return to the counseling centers for follow-up appointments because of other responsibilities or an inability to travel back to the offices on a regular basis (Muldoon,2014). However, 70 percent of the WAYS study conducted by Dr. Emilio Ovuga at Gulu University says that people could receive help for their traumatic experiences and symptoms. Unfortunately, out of that 70 percent, only 17 percent of the respondents reported having recieved help (Ovuga, Amone, Jones, and Abbott, 2013). However, there is not much research to show why these groups of people are not seeking the correct resources available to them. This is the gap that most research done on this topic shows. In a comparison study between females and men who have experienced traumatic events attached to the LRA War, females experience high levels of anxiety and depression, especially female abductees. Their PTSD rates were much higher than the men. This is partially because only half of the women abducted were able to access reintegration services (Muldoon, 2014). The same study concluded that because of the lack of participation in these resources and Logan 16 counseling services, there is not significant enough data to suggest that self-reintegration was not more or less successful than the provided services (Muldoon, 2014). This means that resources are needed in these areas and yet there are none available, leaving the population without aid. NGO’s leaving in 2008 did not help this situation, and mission changes further instigated issues like this. The violence that was occurring in Acholiland not only traumatized those that were formerly abducted, but also those that were living in the rural villages before the IDP camps were opened. These moments of traumatic atrocities drive social and psychological problems especially among the youth and even more specifically in females (Annan, Jeannie, 2011). Even though the men were directly involved in the conflict, the women are more prone to PTSD (Annan, 2011). It is even more crucial that reception centers then become equipped with counseling and education, and eliminate stigmatization of mental health disorders (Annan, 2011). This is because of the detrimental stigma that follows the young women that return from war after being married and producing children in the bush (Annan, 2011). The centers that were supposed to focus on the children’s mental struggles were often times opened up to adults as well due to the overwhelming demand for services in Northern Uganda (Allen, Tim, 2015). Psycho-social support was the most common service offered within the NGO offices; however, the quality of treatment varied depending on which organization was running the counseling. For example, World Vision would facilitate group sessions in which group counseling took place in order to create community (Allen, 2015). In other cases, externalizing trauma by reenacting events and drawing pictures was the solution to coping with trauma. With either method, most of these children were not treated by trained therapists (Allen, 2015). There were also no follow-ups to these initial sessions which resulted in disturbed children to be placed back in their homes while still experiencing extreme symptoms of PTSD (Allen, 2015). Therefore, many services that were offered were inefficient and sometimes difficult to obtain depending on where the victim lives. In order to mitigate this issue of access, the popular idea is to begin to train for peer counseling. This is due to findings that people believe that family, friends, religious workers, and counselors were of large help to mitigate their symptoms once they are diagnosed. Therefore, peer counseling is a short term resource to try to handle the large amount of people that the resources that are available cannot handle (Ovuga Amone, Jones, and Abbott, 2013.). The issue Logan 17 with these methods is that fear of stigmatization or discrimination, break-up of family, lack of means and embarrassment are all factors in which cause a person to not seek help (Ovuga, Amone, Jones, and Abbott, 2013.). This causes resources that are available to become worthless if a victim is no longer willing to seek help for themselves. These are the main topics that are discussed in the research that will be conducted in northern Uganda in order to understand what needs to be done with the growing epidemic of traumatization and mental health disorders and how this connects to the post-conflict era of Northern Uganda as a whole.
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Chapter Three: Research Methodology 3.1 Introduction to Research Methodology This research that was conducted lasted for a month utilizing interviews, focus groups, and a practicum in order to better understand the topic that was being researched. In an effort to answer the research question posed, methods were used to seek out the most accurate information. One of the methods utilized was in the form of interviews with a wide range of demographics but focusing on adults. The decision to study children without the usage of the children themselves was a decision made in order to protect those minors and look at the larger picture of what medical professionals and counselors were diagnosing. It is much more efficient in gathering information and less intrusive on their rights as minors. In reference to the adults, the demographic was diverse. In order to get an adequate response, victims from different atrocities were utilized to investigate the many different ways that trauma affects victims. Interviews were used in order to gather the personal experiences given the intimacy of the topic of trauma. These interviews were done singularly and alone, away from the larger group of people that would be mobilized from the village. This was done in order to protect the sensitivity of the information these citizens were sharing with the researcher. These interviews were recorded with a voice recorder and through written notes taken during the conversation with permission from the interviewee. These one-on-one interviews provide personal experiences and vital data as to how mental health is regarded and effects the larger community and the government perspective on the topic. Recording these conversations is the most accurate way to ensure the exact information is used. The second method utilized in this research initiative was a focus group. The purpose of the focus group in this context is to gather people with similar mental health support experience and understand their perspective on mental health within the geographical area of northern Uganda. It was efficient in collecting data on treatment and the resources available.
3.2 Research Design This research design is cross-sectional because of the way that it works within different demographics that are affected by trauma and its connected mental health disorders. Instead of focusing on one case study, the goal is to cross-compare the different demographics that exist within family units as well as the areas in which they live in. This is being done in order to get a Logan 19 comprehensive answer to the research question and its objectives. There will also be a comparison between government accessibility and NGO accessibility when it is in reference to mental health care and resources to handle PTSD and other mental health conditions that exist due to post-conflict traumatization.
3.3 Area of Study The study was conducted mainly in Gulu, but a week was taken to finish up the preliminary research conducted in Kitgum. In an attempt to survey the most accurate situations the research was conducted within hospitals, rural communities, village town centers, and NGO offices. These were chosen to understand the current situation of trauma in these districts because the two regions were two out of three most affected areas from the conflict, including Pader which was out of the scope of the time given.
3.4 Study Population The population targeted for this study was selected to find answers to the objectives that are laid out for this research initiative. The target population included those that have experienced trauma in the wake of the conflict as well as those who have sought out counseling services in the past or are currently undergoing treatment through the different forms available. The other population selected was who work for NGO’s that support psychosocial movements and resources for the public as well as the government health options available. All of these populations are important in order to have reached a full understanding of mental health care, access, and its many effects on the community. In regards to the civilian interviews conducted, the focus was set on family members and members of the community who are either married or married with children in order to focus in on how trauma affects the family dynamic.
3.5 Sampling Procedure The selection of people to interview was done to target the topic of mental health and trauma. Each interview was carefully chosen based on the person’s experience with the conflict and its effect on their daily life. Therefore, all of the interviews conducted have a connection to either trauma or trauma victim’s resources. The government offices were chosen based on their position and influence in mental health services and resources. In order to utilize these people as Logan 20 gatekeepers to the community of mental health, the questions were formulated in a way to answer the questions related to mental health care, accessibility, and its effect on the family unit. Each interview was conducted with a set of sustained questions in order to receive different perspectives on the same topic but depending on the answers, allowed for deviation in order to investigate different claims when they arose. With these questions, it was requested that each subject give a brief overview of their experience with the conflict in an effort to better understand their experiences in context. In addition, the offices that were visited to conduct research in the NGO and government sector of Northern Uganda were used to further the objective of analyzing the resources that are available to the people of northern Uganda. In order to gain these interviews and contacts, snowball sampling was implemented in order to have the most efficient usage of time and most relevant information using the informants that are available.
3.6 Sample Size The sample size of interviews ranged depending on the type of respondent. Victim respondents ended at 30 respondents and had 12 key informants. This sample size accrued due to snowballing. Key informants were specifically identified and then from their interview they gave suggestions on other respondents that could be of help to the research topic.
3.7 Data Collection Methods The methods used to collect data were mainly interviews with different demographic groups in Northern Uganda. Interviews are important in order to gather primary source data in order to understand the situation on a first-person basis. In order to gain these interviews, purposive selection was utilized in order to identify key respondents. From these key respondents, snowballing was then used in an effort to utilize suggestions given by these key informants. This is essential to this research because of the sensitivity of the information and need for recommendations throughout the entire process. It is also beneficial because it gives the researcher the opportunity to utilize experienced respondent’s knowledge to make the mobilization easier. The other form of collection was a focus group in order to gather group information about the topics at hand. Focus groups are important because the questions asked can be answered in multiple ways with differing opinions, to give a well-rounded view of the Logan 21 problem. These two data collections methods will be aided by a voice recorder (used only with permission) and the handwriting of notes during each session in order to record the information in the moment. This is done so that information is not lost with time. All of these methods are utilized to record the primary sources used to analyze the topics of research. In addition to the field research methods, secondary research was conducted in order to gain access to government documents, statistics, and general information on the conflict, mental health facilities, and the different statistics utilized in this research. This was vital in order to supplement what was being relayed in interviews and support those claims with facts collected through data collection of government offices and NGO’s.
3.8 Data Analysis The research conducted was qualitative in majority, there will be statistics utilized through secondary sources to support the qualitative results within the findings. However, the research collected was analyzed by reading over the interviews conducted and connecting the common themes that are shown through the different answers given. Content analysis was utilized in an effort to categorize field notes into their perspective supporting objective.
3.9 Limitations of the Study Limitations that occurred during the research period were predictable in some areas but less in others due to the inexperience with the culture in Acholiland. Communication was the most prevalent issue amongst the many respondents in this initiative. The direct communication was an issue with the language barrier and a translator was needed in most cases in the villages. The limitation that existed in this sense is that translators sometimes feel it necessary to summarize what the respondent is saying. This does not occur in some situations but for the majority of the sessions it was needed to be requested that translators repeat sentiments and ensure that they were giving word-for-word translation. In some scenarios, it was still ignored and it was felt that some information was omitted because of this communication error. To mitigate this limitation, it took extra time set out to explain that it was the goal to have the exact sentiments relayed and nothing less. In another sense, communication amongst people who spoke English was also a limitation. Because of the differences in culture, one sentiment can mean something very Logan 22 different between the English speakers. In this case specifically, there was an error in budgeting that did not include certain expenses to which the supervisor believed to be clear. This made site visits difficult and different from the plan. A discussion was had amongst staff in an effort to understand each other and communicate, more efficiently, the goals of the excursion. Transportation was also affected by communication. It is main practice to negotiate with a driver a certain price to drive out to a village or district. However, many times because the goal of the researcher and the intended time of the driver were often times mistaken, the monetary value of the trip would rise because of the misunderstanding. This then caused the budget of the research to begin to effect the amount of excursions that could take place and with what means. This limitation caused changes in schedule and often times limited the amount of research that could be done. In addition, because the North is entering into the rain season, the transportation began to be effected with prices going up because of the danger that presented itself in the form of mud filled roads. This not only changed the schedule of the research but also debilitated the travel time out to villages, causing cancellations and sometimes no reschedule date. In order to combat this issue, more time was utilized in the villages that were obtainable in order to still gain valuable knowledge from each interview. Accessing respondents is the last limitation but certainly the one to have the largest impact on the research. It is often times completely normal for respondents to just not show up to appointments made with no notification that this was the case. This made scheduling interviews very difficult and oftentimes unreliable. Because of this, some key informants that would have been important to include in this research, are not incorporated because of the short amount of time given for this initiative and the sporadic nature of the respondents. This means that going forward in the research, more secondary sources were utilized to fill the gaps of possible respondents.
3.10 Ethical Considerations In order to ensure that research is done ethically, measures were taken to complete research that upholds the standards of ethicality. Interviewees were given an explanation of intent before the interview began to ensure they know what the objectives were in this research initiative. In addition to explaining the objectives and intentions of the information to the subjects, it was requested that there is written permission to use their names and answers in the Logan 23 final document. The subjects that did not want their name on the document remained anonymous as per their request. Permission was also sought for recording of the interview to which all subjects were given an opportunity to agree or decline to allow the researcher to record the session and take physical notes. When researching in offices of the government, special permission through the CAO was sought out before conducting meetings within the local government. This included copies of a letter of intent given from Student for International Training regarding the intent of the research and the permission given to conduct such research. One copy was kept on person at all times. In conclusion of ethics in this research, the researcher strived to ensure that ethical considerations were held at the utmost priority throughout the research period; keeping privacy and protection of the interviewees at the forefront of each interaction made during this research period. Each respondent was given a consent form outlining the research and their rights as a respondent to remain anonymous or for their information to remain confidential. Translators worked diligently to ensure that respondents understood the means behind the consent forms. Even when respondents gave permission to use their names, it was of the opinion of the researcher that they still remain anonymous because of the sensitive nature of the topic. Compensation was also a consideration going into the villages especially. Because these members of the community were taking time out of their work schedules to participate in this study, it was discussed with the LC one of each area what the appropriate gift would be. This could include a soda, soap, salt etc. However, it was always given after consultation of the person in charge of the area that was being visited.
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Chapter Four: Findings and Analysis The research conducted over the past month sought to answer questions that are left unanswered by many scholarly research initiatives done in the Northern Ugandan area. Most research conducted focuses on the trauma of only those that are formerly abducted. However, there is an entire population of people that existed during the conflict that were left to run for the IDP camps and hide from the LRA. There is no mention of the general population of people in most articles and news reports and for this reason, the research seeks to find out about the trauma that existed in all demographics of people in Northern Uganda. More specifically, how these demographics interact with their family members and how that affects daily life. After finding the relationships and the effects on family members, the resources are the next important step in analyzing the trauma treatment environment in Uganda. Multiple NGO offices were sought out to discuss the resources that are offered for those that are suffering from lasting effects of their traumatic experiences. With this, the research identifies the different forms of trauma induced disorders resulting from the conflict in an attempt to survey the effects of trauma in a broader sense. In the four weeks of time, these are the findings that each of the objectives sought out.
Objective One: Analyze and Define the different forms of mental health disorders resulting from the LRA Conflict.
In an attempt to provide and analyze the different forms of mental health, the basics were sought out from professionals on what they had seen in the field and how this affects the daily lives of those who experienced atrocities during the conflict. Therefore, it was important to come up with a list of mental health disorders associated with trauma and that are common in Northern Uganda. These are: Post Traumatic Stress Disorder (PTSD), depression, paranoia and delusional behavior, and anxiety. Before listing and defining each of the symptoms and how they present themselves in northern Uganda, it is important to understand how war effects those that are traumatized and why they are. This unpacking of issues is one of the forefront missions of the Center for Victims of Trauma (CVT). War can cause disruptions in the following areas: material, physical, social, and mental. Logan 25
“In the material world, there is a loss of material resources like houses, schools, food, water, and work. In the physical world it causes loss of health, death, injuries, and disables some people to the point of losing capability to function physically as they once did. In the social world, it creates a disruption of social networks, community structures, formal and informal groups, traditional organizations, and social rules. Finally, it effects the mental world in which it can cause loss of control of one’s life, decreased quality of life, loss of sustaining values system.” (CVT Training Session Slides, April 25, 2016). This is the key foundation of how trauma is looked at from a psychological and social point of view and is crucial to understand how trauma then effects everyday life for the citizens of Uganda. From speaking with trauma counselors in the area, Thrive Gulu’s experience with depressed individuals suffering from depression is that they often times socially isolate themselves (Thrive Psychosocial Counselor, personal communication, April 22, 2016). In this way, depression can take over a person’s life, causing them to be disinterested in everyday living. The types of experiences that can lead to depression as a symptom is the loss of a loved one, the witness of mass atrocity or the socioeconomic status that a victim is experiencing post- conflict (Thrive, personal communication, April 22, 2016). Because of this, many counseling NGO’s have decided to add economic empowerment to their activities but this will be discussed later in the findings. Depression causes feelings of helplessness and hopelessness, loss of interest in daily activities, appetite or weight change, change in sleep schedule, mood swings, loss of energy, self-loathing, reckless behavior, and unexplained soreness in the muscles (National Institute of Mental Health, 2016). These symptoms can be very harmful in the society that prides itself on manual work out in the fields (Thrive, personal communication, April 22, 2016). Unfortunately, this means that those that suffer from depression often times are stigmatized as lazy and worthless. This was seen first-hand during a focus group in the village in Abwoch. The women being interviewed criticized the young woman who had said her feelings and thoughts often cloud her from finishing work (personal observation, Abwoch, April 23, 2016). Observation of the reactions of certain admitted feelings and behaviors led to the realization that even if the patients are in a support group for these feelings, often times they are not accepted for certain Logan 26 behaviors that they exhibit due to depression. Unfortunately, this does not aid in their recovery and often times agitates feelings of anxiety and paranoia that what they are feeling is not normal and they should be ashamed for it. The symptom of paranoia when associated with trauma is unfortunately another debilitating set of behaviors that can cause a person to withdraw completely from the community. It is also an extremely difficult symptom to treat. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution, threat, or conspiracy. It can cause irrational behavior and delusions that are unbreakable in the mind of the victim (Institute of Mental Health, 2016.). In the case of Uganda, paranoia is very prevalent especially for those that experienced atrocities during the LRA raids and warfare. There is a belief in some people that the election violence would bring about the return of the LRA (Focus Group, Kitgum, February 21, 2016). The fear of their experiences is so ingrained in their psyche that it keeps them functioning in daily life. Because there is so much uncertainty in the fate of each area during election season, some victims often begin to withdraw from the community in case of a second war. This causes work to go undone and often times causes some to quit their jobs because of the fear that something might happen while they are away from home (Focus Group Observation, Kitgum, February 21, 2016.). From listening to many different respondents, each experience with trauma affects different aspects of their attitudes and their fear. For example, a man who entered the hospital in Gulu was there for routine treatment that he had been receiving for months. Upon arrival, his mood immediately changed as if a switch flipped and he instantly became defensive. He had forgotten that he had brought himself there and began to irrationally question every move the nurse was making. He was paranoid that the nurse on staff was poisoning him and became even more defensive. It was explained to the researcher during this observation that this man was being treated for paranoia based on experiences he had when he was a child (no detail was given to protect the patient) but it was left to the understanding that it was trauma related. His paranoia began to affect his ability to receive the medicine that would make his feeling subside because of a linked experience from his childhood. It then became increasingly difficult for the staff to subdue this man to administer necessary medication. The situation then turned violent on the side of the patient. He began to fight the medical staff in an attempt to escape the “torture they were attempting to inflict on him (Personal Observation, April 20, 2016).” Paranoia had completely taken over the situation. Logan 27
In another case, a woman in the village explained that when she is out in the fields, she cannot stay for long because of the overwhelming fear that she is going to abducted from the fields like she was a young girl. Therefore, she frantically searches the area while pulling crops in an attempt to clear the area for her safety. In some cases, she even interprets small noises as gunshots and immediately runs back home to stay inside for the day (Anonymous, Awach, April 19, 2016.). This effects not only her work ethic but also her personal wellbeing and feeling of security in her own home. She later divulged that it creates quite a stir in the community and there is a stigma around her actions and many people have labeled her as “disturbed.” Ultimately these feelings that she is experiencing is linked to her abduction in the early 2000’s. Her traumatizing experiences have debilitated her ability to function in normal daily life. Both of these examples are common in the world of paranoia and anxiety. Some even develop into Post Traumatic Stress disorder (PTSD) which is the most common disorder that comes from trauma in post-conflict northern Uganda. According to Okot Benard Kisozi, a trauma counselor with Refugee Law Project (RLP), PTSD comes in different levels depending on the victim’s experience and for how long they were exposed to these experiences (Okot Benard Kisozi, personal communication, April 20, 2016). PTSD is a combination of all of the above conditions (anxiety, depression, paranoia, and delusions) but in different severities working together. Some victims experience nightmares, flashbacks, and hallucinations connected to the atrocities that they were exposed to. In addition to these, they are extremely mistrusting, suicidal, and often times sensitive to human contact if they experienced a physically traumatic wound. It is because they re-experience their traumatic events in varying degrees (Kisozi, personal communication, April 20, 2016.). Its categorized as psychosis because of its effects on the psyche. It makes a victim believe truly that their thoughts are reality. Aside from the symptoms of PTSD, it is a disorder that from observation is one that is far too quick for people to label victim’s with. Several professional respondents from the NGO community expressed that the issue with some of the local counselors is that they are very hasty in diagnosing PTSD because of its commonality amongst war victims (Kisozi, Marini, et al. April 2016). Because of this there are many complications resulting in wrong diagnosis and prescription overdoes resulting in poisoning. This is an issue discussed in objective two in more detail, however, it is relevant to analyze how it is portrayed in the Northern Ugandan community. Logan 28
Because PTSD is the most common trauma related illness, many different demographics affected by it and they all experience varying degrees of it. There are three groups affected by trauma, more specifically PTSD. These are: the formerly abducted, civilians, and the children of both previous groups. The first group, the formerly abducted, were found to have more efficient services and resources because they were received by their communities and through NGO’s and immediately began rehabilitation. They are then monitored over the course of two years by their sponsoring program and given counseling on the traumatic events that they may have experienced while in the bush. This was explained by the organization AVSI, an office that focused much of its resource allocation on psycho-social support for the formerly abducted (AVSI Department of Health Officer, personal communication, February 22,2016). The former counselor for that project explained that because of their mental health, there was a stigma that followed the former child soldiers. This arose because of their violent nature in the bush. There was also a fear that these violent tendencies would return at any moment while at home in the community because one of the symptoms of PTSD is flashbacks and irrational behavior because of them. Stigmas also follow the young girls that were abducted due to their sexual assault cases and their often return with children from forced marriages in the bush (AVSI Department of Health Officer, personal communication, February 22, 2016). Because these children were introduced to such visceral violence, the lasting effects stay with them even when an organization deems them able to reintegrate back into society. PTSD unfortunately can relapse at any moment and many counselors criticize the brief nature in which the formerly abducted were treated for their PTSD. In one anecdote, a former counselor explained that one of her clients was tested to continue treatment for another year but he did not return to the center. It was later discovered that the boy had a traumatic flashback while gardening with his younger sister and began to violently yell at her. When she did not respond in a fashion that was preferable to him, he beat her to death with the hoe they were using to dig up the land (AVSI, personal communication, February 22, 2016). It was said that he had a flashback to his days as a soldier in the LRA and his traumatic experience took over his senses and his sister soon became not his sister but rather a fellow soldier that was “slacking in the field.” An analysis of this situation is one of the many reason why families are so heavily affected by each other’s experiences which is discussed later on as its own objective of the findings. Because PTSD is not recognizable to the standard civilian, stories like this exist in Logan 29 many different areas that were largely affected by the war. This stems from a misunderstanding of the concept of trauma related disorders and an ignorance to trauma affecting emotional well- being. An issue with a lot of research preliminarily done on trauma is that they focus solely on the formerly abducted. However, it was the goal of this research to identify the other citizens who were gravely affected by traumatic experiences that happened as a result of the conflict, those that were left behind to gather their lives after raiding and pillaging and find themselves in camps. Because after all, there were two-hundred fifty-one camps across eleven districts that contained nearly two million people (UNHCR, January 6, 2012). Therefore, it is extremely important to include them in the group of traumatized people which is something that a lot of the research done leaves out. Inevitably now, the second group, the civilians, are those affected by raids that occurred in the villages in Kitgum and Gulu. When speaking to the people who live there, it became apparent that resources were not available in large capacity for those that were not abducted. Aleng Polly, an elder in the IDP Camp, explained that only one NGO was present during the time of encampment. After encampment, the NGOs were only present for a few months, counseling very few with no follow-up appointments. They pulled out of the rural areas around 2008, only two years after the official end to the conflict, leaving many with untreated and undiagnosed mental health disorders. (Aleng Polly, personal communication, February 21, 2016). This is relevant to this objective in the sense that PTSD presents itself differently in those that fled to the camps. They were not offered the same resources as those of the formerly abducted and so many symptoms that present themselves in this group of people are very different. This is because of the agitation of the symptoms of the years of no diagnosis. The third group is that of the children of the above referenced groups. According to the Akena Fred David, a school teacher in Amida, he witnessed the youth of the community suffer alongside of the adults who actually witnessed the atrocities as they occurred in the villages (Akena Fred David, personal communication, February 20, 2016). The reason for this is that their parents are suffering from mental health disorders and are, as a result, affecting their children’s mental health. The issue is that PTSD and other symptoms are presenting themselves in children in extreme cases that have led to suicide or behavioral issues. David explained that he believes that the counseling situation is incredibly critical because teachers are not equipped to counsel the children and the parents of those children are suffering in ways in which they may Logan 30 not even realize (Akena Fred David, personal communication, February 20, 2016). Because of this, suicide rates have increased in the community. He recounts a time, in which a few weeks previous, a student had left his class during their lunch break, went home, and committed suicide. In this case, he explains that similar suicides could be prevented if only there were resources to diagnose and council those with traumatic stress (Akena Fred David, personal communication, February 20, 2016). Unfortunately, due to what one can assume as ignorance as the reason leading officials to not recognize or define symptoms in these children and that is why it goes undiagnosed. It is crucial to the mental health world moving forward to sensitize people about the way these symptoms present themselves and what types of disorders can result from trauma. Which as of this study today, is lacking in the municipalities studied. The issue of trauma is one that proves to be a challenge for Northern Uganda because of the lack of awareness of the symptoms that can arise from traumatic events. This was made clear through a visit to the International Committee of the Red Cross to discuss the current status of the mental health crisis in the Kitgum Municipality (Anonymous, personal communication, February 22, 2016). People in the rural villages are unaware that they may be suffering from post-traumatic stress disorder, depression, etc. This is a problem because Kitgum and Gulu are two of the most affected municipalities in the North due to its position near South Sudan and its proximity to the fighting occurring between the UPDF and the rebels. (Anonymous, personal communication, February 22, 2016). Because of this, many civilians were victims of human rights abuses on behalf of the UPDF soldiers and the LRA rebels. Unfortunately, this is the finding amongst those that are diagnosed with PTSD and other trauma related disorders. When trying to define and analyze these disorders it became increasingly clear that many are ignorant to their causes and how they present themselves. Those that do know are unreachable by village members and understaffed to spread the sensitization of the symptoms. This is going to be analyzed in the following section. However, an analysis of the findings of the different types of disorders that exist lead the researcher to the conclusion that there is a lack of knowledge amongst a lot of the symptoms and signs of the stages of trauma. They come under different names amongst those in the rural communities like “bad thoughts,” “spirits,” “headaches,” “visions,” and “tiredness.” This is not due to a refusal to accept the medical terms. It grows from an ignorance of the real disorders that exist within the mental health field. From an outside perspective, one of the main combatants to this issue is to sensitize Logan 31 the community. Ensure that rural communities are able to learn about the many different detrimental disorders instead of constantly being told their symptoms are laziness, bad spirits, or general bad behavior that makes them a worthless person. These stigmas often times make symptoms worse and do not benefit the victim in anyway. Because of these harsh ideas of PTSD and others, or the lack of knowledge on these symptoms, victims suffer and continue to agitate their symptoms into unbearable conditions. This is where the efforts towards trauma treatment becomes imperative in the search for answers for those that suffer.
Objective Two: Analyze the efforts towards trauma treatment and access to them
When the conflict in Uganda began to expand towards the end of the twenty years, NGO’s began to move into the area in order to try to mitigate the aftermath of the effects of the war. Trauma affected not only the formerly abducted but also the citizens left behind. In an attempt to understand what resources are utilized in the post-war setting to tackle these traumatic experiences that so many were exposed to, a survey of the current efforts was performed. These are the findings of those efforts and their current effects on the communities.
Psychosocial Support vs. Psychological Support It was learned during this research period that there are two different approaches to those that have experienced trauma. These are: psychosocial support and psychological counseling support. In order to understand the approaches taken, the necessary comparison is done to clarify a common misunderstanding. These differences were explained by Gabrielle Marini who heads the Center for Victims of Trauma and who is responsible for trainings many of the professionals in the NGO world to handle victims of trauma. Many people confuse counseling and psychosocial support and so it is important to differentiate between the two. Psychosocial support helps to build resiliency in the community in an effort to support families to provide for their physical, economic, educational, social and health needs of their children. It is a non-therapeutic intervention intended to help a person cope with stressors at home, work, school, or in the community (Gabrielle Marini, personal communication, April 25, 2016). If an NGO is organizing a social event, it is with the aim of promoting changes in the perception and quality of the social relationships of the participants. It is a way to generate social Logan 32 skills of the participants and create social links of similar qualities. For example, Mental Health Uganda utilizes this tactic when creating support groups. Those with similar experiences are grouped together to support each (e.g.: trauma). Psychological counseling is a process which empowers people to achieve chosen targets related to chosen areas of their life. Its goal is to create social, emotional, relational strength and psychological health through relational processes (Gabrielle Marini, personal communication, April 25, 2016). This means that organizations often involve verbal, physical or artistic expression in order to create strength in all aspects of life. This can be done through talking/group sharing, drawing, drama, music or just general play. The important difference that can be made between the two approaches is that counseling addresses the internal world of clients and how this affects their thoughts and feelings versus what is happening in the external world (e.g.: food, water, school fees…etc.). The Center for Victims of Trauma utilizes counseling to change the vision of the victim of themselves and give them opportunities to achieve what they wish. This brings a victim to fully understand their own functioning and why they are feeling the way they are. Through this they can learn strategies to cope and move forward. From the time spent between the two municipalities (Kitgum and Gulu) if you ask anyone who has had some form of help for their traumatic experiences is asked what they have gained from the resources that are available, the answer is almost always material items (personal observation, April 2016.). This is because so many organizations focus on the economic needs of their clients, not the psychological needs of their clients. Often times, the need to have food, a budget, and have livestock takes over the psychological need for counseling and a debriefing of their thoughts and feelings. This is because as discussed with Gabrielle Marini, psychosocial support does not have an initial aim for the participants to achieve psychological changes and there is not a lot of room to reflect about psychological changes provoked by the social interaction (Marini, personal communication, April 25,2016). However, in counseling, the victim is seeking psychological change and there is plenty of space to reflect about how psychological changes lead to practical changes. From the different programs analyzed in the two municipalities, very few offer direct counseling and the majority of them are solely psychosocial based which does not necessarily tackle the traumatic feelings that some experience. With counseling, there is an obvious Logan 33 evaluation and diagnosis which can later lead to a psychiatric approach where medicine is prescribed along with the counseling methods. In the experience of the research it can be concluded that more counseling is needed in order to make these programs successful. Because counseling involved skilled counselors, clear definition of services provided and creates a regular follow up assessment it creates a relationship with the client and the counselor as well as steps and goals to move forward and heal from their trauma (Marini, personal communication, April 25, 2016). It is the very backbone of recovery and it is lacking in many of the NGO programs that try to make economic empowerment the epicenter of their psychosocial support programs. If the problem of PTSD in victims is to be mitigated, the area cannot continue to ignore the gaps in their resources. Concluding the comparison of the two different types of action taken it is observed that if the client needs both psychosocial support and psychological counseling, the events need to be separated. If they are not clearly distinct then the lines begin to blur and other issues begin to occur. There needs to be isolation of external realities and internal realities in order to heal in both ways efficiently (Marini, personal communication, April 25, 2016). This is so vital in the attempts to start to chip away at the amount of distress victims see while experiencing things like PTSD but also are suffering economically as a result of other factors from the war.
Analysis of Efforts Towards Trauma Several NGO’s were visited in an attempt to flush out all possible options for those suffering from trauma in their lives. Both Gulu and Kitgum were at one time the epicenter of the NGO offices during the height of the conflict and unfortunately has since dwindled in its access to resources. The following findings are in discussion of that factor and conclude with the current resources available and how accessible they are to each demographic. There were several NGO’s in 2006 that prided themselves on their psychological resources. However, many of them withdrew out of the rural communities two years after the conflict and those that stayed in the area began to change their missions to alternative methods of humanitarian aid. Unfortunately, when the conflict ended many lost funding for certain projects and psychological aid fell aside. It has happened to many different organizations, Invisible Children being one of them. Invisible Children Uganda (IC) prided itself on its reintegration services, ignoring the mandate from UNICEF that child soldiers cannot be held in rehabilitation Logan 34 centers for longer than three weeks and instead catering to each abductees needs (Invisible Children Uganda, personal communication, April 7, 2016). It closely focused on follow-ups and creating a safe space and community for those formerly abducted with different time tables of recovery for different people. Because of the stigma against the formerly abducted, IC Uganda focuses on skills training and counseling in order to help those victims find a home for themselves if their home is unwilling to accept them back. This is something that a lot of organizations lack; the ability to cater to the specific needs of each person instead of making generalizations about a group of people suffering from the same symptoms. Even though Invisible Children Uganda no longer offers rehabilitation services, it continues to believe that trauma counseling is the most needed post-conflict service in Northern Uganda today (IC Uganda, personal communication, April 7, 2016). It is believed that, unfortunately, the services offered in these days are only scratching the surface of the issue and do not take enough time to delve into the more complicated issues that plague traumatized people (IC Uganda, personal communication, April 7, 2016). IC Uganda currently focus on the community based approach and travel out to the field with the belief that in order to help people one must go to them because they will never come to the organization (IC Uganda, personal communication April 7, 2016). In many ways this idea has been adapted by a lot of NGO’s and CBO’s with the intent of community outreach. Although there are not many, Kitgum has a few options for psychological support. Many organizations focus on community building and economic empowerment as their main focus. Meeting Point in Kitgum, a psychosocial approach, is one of the few organizations that were present during the time of encampment within the camps and was the first to offer psychosocial counseling in the Kitgum area. Its main focus being to support those who were sexually assaulted and diagnosed with HIV/AIDs which not only generated depression and anxiety but also came with PTSD from their assault (Meeting Point, personal communication, April 11, 2016). In this case of PTSD, group counseling is very efficient for the fact that it creates a support group of others suffering from HIV/AIDS and the resulting traumatic experiences that brought them there. In this case, the services offered are community activities to support positivity, truth sharing, and other art infused groups to combat stigmatization and create a positive lifestyle for those diagnosed. Meeting Point’s efforts are solely based in Kitgum and offered only to those specific to HIV/AIDs patients. Logan 35
Kitgum Concerned Women’s Association (KICWA), a psychological counseling approach, was one of the few that focused on family counseling within the formerly abducted and their reintegration process (KICWA, personal communication, April 11, 2016). It adds cultural ritual and counseling to the table as a unique approach to the many formerly abducted that came through its center. In its eyes, the key to recovery from traumatic events that continue to plague a person’s mind is utilizing the tactics that the person believes to be comforting (KICWA, personal communication, April 11, 2016). For example, if religion is the factor they trust and are comforted by, their recovery is tailored to this consideration or if the family is in danger of being affected by the symptoms the victim is exhibiting, their family is brought into the counseling sessions. This is important because many times PTSD/depression etc. effect not just the victim but also those around them. Along with KICWA, Live Again (LAG) Kitgum, a psychosocial approach, was the first of its kind to include all trauma victims, not just the formerly abducted and they still exist today and continues to seek out communities suffering from the aftermath of the war. During discussion of the resources it offers to the communities, it was expressed that LAG believe that community counseling is the most efficient way of counseling those with traumatic emotional experiences. This is because (as per the director) “if you think about a victim as a leaking bucket, in a group of leaking buckets, they use each other to save each other’s cracks (Live Again, personal communication, April 11, 2016).” It is the idea that all of them are suffering but can rely on each other to mitigate the symptoms because even though their dark feelings are not ever fully going away, they all try to soften the blow of each other’s episodes (LAG, personal communication, April 11, 2016). Unfortunately, this is also the argument against sole community support. The intention is a positive thing, however, often there is no professional psychologist involved in the individual lives of each person. This means that some are left conforming to the treatment that is given to the group. Breathing techniques and grounding are important for anyone to understand in order to help self-heal. However, trying to categorize trauma victims into one box for treatment is an oversight that unfortunately does not create progress for a victim. Live Again is in the process of growing to become more of an individualized approach to counseling but the funding is still not adequate to hire additional staff for it (LAG, personal communication, April 11, 2016). However, like many organizations that phased out, it is hard to find counselors willing to take on these victims because of the exhaustion that is also seen on the Logan 36 side of the counselor. Counselors take so much time working to heal other people that they find themselves suffering mentally as a result of the many different disturbing things that come from post-conflict experiences (LAG, personal communication, April 11, 2016). It is true in most cases where counselors are so few. Through the experiences with many different offices in the area, the research has shown a problem with getting counseling to these areas does not just end with funding. It is also an issue of exhausted staff, those that leave the profession in an attempt to take care of themselves and ensure they themselves are not falling into a disturbed state of mind. And this is very common amongst counselors who deal with trauma, as the director of Live Again said, “As a trauma counselor, you must protect yourself so as to not get disturbed yourself (LAG, personal communication, April 11, 2016). This finding is increasingly interesting because it is something that not many counselors or organizations admit to. The idea that fatigue can affect the amount of interest in taking a job like psychological counselor is something that comes from, what the researcher assumes from the experiences with NGO’s in Gulu, the overload of clients that come through these organizations and the inability to take breaks due to short staff creates exhaustion; an understandable reaction to the compiling of so much depression and trauma. Unfortunately, this is not taken into consideration by any office that was visited except Live Again. This means that many counselors go without their own mental health breaks from the heavy stories and experiences that their clients present to them. It is one of the issues that explains short staffing and the increasing reliance on community support systems. Kitgum uffers from this issue because of the already lacking resources that exist for those traumatized. Therefore, this is a pressing issue to be considered in order to efficiently reach those that need help. In Gulu, there are several offices still practicing psychosocial and psychological counseling tactics within the neighboring areas. For one example, Mental Health Uganda and Caritas both share similar tactics in their attempts to utilize psychosocial activities to mitigate those that are traumatized. There are savings programs and group sharing sessions (MHU, Caritas, personal communication, April 2016). The purpose of their psychosocial programs is to try to mitigate the external forces that are not helping their internal struggle. Therefore, savings programs and livestock exchanges are done in an attempt to alleviate the economic struggle that often times causes unneeded stress. Logan 37
However, it was discussed earlier in the findings that focusing solely on economic empowerment is not as successful because it ignores the counseling aspects that are needed to address the traumatizing events that took place in their lives in order to get better. This is where Mental Health Uganda takes a step forward in its attempt to also provide the hospital services from the Mental Health Unit to those that are participating in its groups. This can mean connections with prescriptions in which can be prescribed by psychiatric doctors and then given to those that are diagnosed with disorders like PTSD (practicum observation, April 2016). Because this organization is directly connected to the hospital in which hosts their office, there are a few more resources that are available that assist within the medicinal approach to mitigating symptoms of trauma. However, one must be careful in suggesting that medicine is an efficient approach to treating those with PTSD. In discussion with Okot Benard Kisozi on his experiences in the field as a counselor, aside from his work with trauma healing through Refugee Law Project (RLP), prescriptions can cause a dangerous issue to form. The problem stems from an issue entirely before prescriptions occur. It was discovered through this discussion that many counselors and organizations are actually very quick to diagnose with PTSD without looking further into the symptoms that a client could be experiencing (Okot Benard Kisozi, personal communication, April 20, 2016). For example, just because someone is experiencing nightmares, does not always equate to PTSD. It could be a result of anxiety in a stand-alone form. However, this is another issue in itself. There are two major problems with some of the resources that are available to those that need them. One of which is that there is a lack of training and understanding by some in this area on what PTSD looks like versus many other disorders that can come from trauma (Gabrielle Marini, personal communication, April 26, 2016). From the trainer prospective, Gabrielle has seen the misconceptions made about victim’s mental health and he explained during the interview was that many counselors are often times consumed with too many clients. That they are quick to stamp a diagnosis on their client to move onto the next. The issue with this is that this then leads to the second problem that arises in the form of malpractice. The misdiagnosing of victims can also lead to the wrong prescription of medicine. During this research, in the villages of Awach and Abwoch, it was found that every victim that was spoken to was prescribed some form of medication for their symptoms. This is normal if they are Logan 38 exhibiting signs of symptoms uncontrollable by counseling. However, it was concerning to observe the magnitude of prescriptions given out to so many clients. This is because, according to one respondent, drug poisoning is an issue that is rising in the ranks of problems with malpractice (anonymous counselor, personal communication, April 20, 2016). If the medicine is clinically prescribed and explained correctly with clear instructions and follow-up appointments, it is an efficient way of help a victim contain their feelings and physical ailments that come from PTSD. However, quick diagnosis leads to incorrect prescriptions which can be isolating to victims. What is intended by this statement is that it is found that there is a direct correlation behind lacking knowledge in disorders from trauma and drug poisoning issues in the villages. This further demonstrates why counseling is so crucial. Counseling creates a relationship between client and counselor. There is a check-in process and concern for the general well-being of the person being counseled. It is of the opinion of the research that counseling supersedes medication and RLP reinforced this opinion during an interview after the discussion of medication prescription issues (Kisozi, April 20, 2016). Because medicine can be prescribed and left up to the client to pick up, there is no follow-up and certainly no focus on instruction on how to take it. This has shown to lead to addiction, misuse of the drug, and sometimes even death because of overdose. These are all things that Benard had seen in the field prior to this research. However, the many trips to the village conducted during this research solidified the unhealthy reliance on medicine to “improve.” From the perspective of psychological counselor Gabrielle Marini, drugs should be considered a “short-cut” to recovery for victims (Marini, April 26, 2016). There is an issue, then, when drugs become one of the only things helping a victim with their traumatic experiences. It creates a reliance on the medicine to make them feel better about their situation. Unfortunately, this means that when the common issue of drug shortage in health centers and small clinics out in the village, many people go without their prescriptions for weeks until the stock is replenished. As a first hand witness, this happens quite frequently and occurred twice during the time spent out in the villages (Personal Observation, April 2016). The lack of resources in the medicine world is an issue entirely and not within the scope of this research but it is important to note that reliance on drugs that sometimes are there and sometimes not can be dangerous. Irritability and distress are caused when a victim realizes the only thing “keeping their bad thoughts away,” was the medicine prescribed (focus group observation, Awach, April Logan 39
19, 2016). Observations of responses to questions about coping turned into irritated responses about the shortage of drugs in every conversation, gives into the assumption that there is an extreme reliance on the prescribed medications. This issue in itself can be mitigated by an increase in counselors. However, it was explained by Gabrielle Marini that the issue with northern Uganda and its lack of counselors, is that many of those people that go to school for counseling, end up going directly into a teaching or academic role without actually going out into the field (Marini, April 26, 2016). Therefore, there is not enough field workers to accomplish the work that needs to be done, a general issue that leads into the topic of access to these resources that are available.
Access to Resources Accessing resources for those that live in Gulu Town or Kitgum Town is much easier for those within walking distance. However, if a victim of trauma resides outside of town and in the villages, accessing counseling, hospitals, and other services is extremely difficult. For example, mental health specialists do not exist within the rural communities, they do not begin to populate until Health Center IV within the Ugandan medical facilities which for some families is very far from where they live and very expensive to travel to (Baingana & Mangen, 2011). In addition to the proximity, patients are then at the hands of short staffing with only one psychiatric nurse at that level. NGO’s face different obstacles, budgeting for which communities to visit becomes a factor in how many can be visited and how frequent, an observation made during the practicum time in the hospital. Therefore, if it is not in the budget to go out to the field, those communities are not visited and those communities certainly do not have the resources to travel to the NGO offices. Because of this odd predicament, many have turned to community support in order to cope with their grief and depression. The focus group discussion on trauma and recovery gave insight as to what means the civilians used to counsel themselves in their times of need (Amida Focus Group, personal communication, February 21, 2016). When asked if they knew that mental health services were being offered in Kitgum Town, they answered unanimously that they did not. With further questioning, it was found that not only did they not know that there were services being offered, but they would not seek out those services due to the lack of transportation options to access their sessions if they were to register for counseling (Amida Logan 40
Focus Group, personal communication, February 21, 2016). Instead, the women find support amongst each other. They talk to each other and encourage each other towards a better life. When questioned about the men in the village, they do not speak about their struggle due to the fear of being stigmatized as weak (Aleng Polly, personal communication, February 21, 2016). It was clear that self-counseling was not enough, however, because many were still suffering from the different aspects of their trauma. Accessibility to mental health services is a growing problem for the rural areas in Acholiland, no matter which of the three groups the victim belonged to (formerly abducted, civilian, or child of both). When the World Health Organization (WHO) surveyed the situation in 2012 it was reported that 90 percent of mentally ill people are never treated (WHO, 2012). This theme was carried out through the different offices that were visited in order to understand the options that the people in Amida, Kitgum and Gulu’s surrounding areas of Abwoch and Awach, have if they find themselves experiencing mental health disorders as a result of trauma. To better understand these resources, it will be broken down into two types of aid they can receive, the government mental health services and NGO counseling and psycho-social support. The government mental health services are few in the Kitgum district. Only five psychiatric nurses to tend to the entire municipality, according to the mental health focal person, (Mental Health Focal Person, personal communication, February 22, 2016). An important factor is that these nurses work out of the government hospital which is located in Kitgum Town, a long commute for villagers that need healthcare, but cannot afford the transportation (Aleng Polly, personal communication, February 21, 2016). Because of the lack of staff, there is a longer wait for treatment and resources become scarce for those that need immediate counseling or diagnosis. In an effort to understand why there was a lack of staff in this hospital in the mental health department, the District Health Officer (DHO) was questioned about the funding and resources allocated to the healthcare system. It was found that the reason to which there are so few doctors and nurses able to treat mental health disorders is because the budget for healthcare for Kitgum is formed in such a way that there is no room for allocating more staff (District Health Officer, personal communication, February 21, 2016). In theory, the DHO explains, the local government that is involved with the Ministry of Health meets at the end of each month to discuss the resources used and needed for that month. Once the numbers have been finalized, they then send that report to the Ministry of Health and look for turnaround with more money in Logan 41 the budget. However, an increase in budget rarely occurs (District Health Officer, personal communication, February 21, 2016). According to the Mental Health Focal Person (Mental Health Focal Person), the government adequately supplies this department with all of its needs. However, the contradicting statement made directly after that was that some patients have to pay for the supplies that are used at the hospital because of the lack of resources (Mental Health Focal Person, personal communication, February 22, 2016). Those resources consist of medicine for those that suffer from anxiety and post-traumatic stress disorder, psycho-educations to raise awareness about mental disorders, and social workers for formerly abducted children who need counseling (MHFP, personal communication, February 22, 2016). However, the problem lies in the inability of rural villagers to have access to transportation to take them to the government hospital to obtain these services. For example, one woman from the village of Gang Lela is a victim of trauma due to her experiences during the conflict. All of her children were taken from her, two were killed, and the other four abducted. This was evident due to the immediate grief that was displayed at even the first mention of conflict (Anonymous, personal communication, February 21, 2016). When asked if she knew if mental health care was provided for those who suffer from traumatic events, she answered that she knew only of the government hospital which was too expensive and too far for her to travel to at her age. Therefore, she never found any motivation to seek out counseling for her grief and trauma (Anonymous, personal communication, February 21, 2016). Her story is not unique in the sense that many have never sought counseling for their depression or PTSD. A man who violently lost his wife, relayed a similar story as to why he never sought counseling for his grief or depression (anonymous, personal communications, February 23, 2016). Due to the violent nature in which he lost his wife, his trauma began to consume him. He explains that he even tried to commit suicide more than once because of his grief (anonymous, personal communications, February 23, 2016). However, even though he was experiencing such depression, his believed that concealing his personal grief would solve itself eventually. As a result, he never reached out to any of the organizations that he knew existed for counseling due to his belief that the travel time was inconvenient and not worth his possible work hours. Instead, he found an elder in the community to speak with on a daily basis and eventually he had an unnamed traditional ritual performed in order to find peace (anonymous, personal Logan 42 communications, February 23, 2016). The stories are continuously similar from all of the villagers: They did not receive formal counseling because they did not have the means to travel to obtain it. In other arguments, the time that it takes to travel to receive these services takes them away from their farming and time in the fields, which affects their livelihood. Another challenge to accessing efficient mental health care is traditional methods of healing. This is one of the more significant challenges to treating mental health in the rural areas. For example, the Gang Lela Village in Amida is headed by a chief who believes in the power of traditional medicine to treat community members who suffer from PTSD and mental trauma. In his terminology the typical mental health vocabulary does not exist. For example, PTSD, in his belief, is the result of tragedy occurring and the spirits of the deceased are haunting those that witnessed or carried out the atrocity (Kitgum Rwot, personal communication, February 23, 2016). The problem with this is that Rwot is more likely to suggest treatment through traditional methods like cleansing ceremonies and herbal remedies which in most cases in this particular village, have not been enough to stave off the traumatic symptoms of PTSD. This was seen in an interview that had been scheduled with a formerly abducted child soldier whom the chief had suggested would be relevant to the research topic because he had been recently cleansed by mato oput (Kitgum Rwot, personal communication, February 23, 2016). This is a ceremony meant for reconciliation of those that return from the bush. However, this interview was not completed because the young man disappeared at the time and date of the intended interview. The Rwot had explained that it might have been because he suffers from “flashbacks” of his time in the war (Kitgum Rwot, personal communication, February 23, 2016). He had never referred this boy to counseling even though he has a history of spells of rage, flashbacks, and trauma induced anxiety; all symptoms of extreme PTSD. This is indicative of the attitude of the traditional leaders on mental health. He believed that the traditional methods of rehabilitation would be enough to settle this victim’s PTSD and had convinced himself that the methods had worked, when clearly there was still a lot of damage still present to this young man’s mental health (personal observation, February 23, 2016). It is detrimental to the recovery of the village if its leaders are unwilling to provide them with the services that they require to live a healthy lifestyle. Therefore, regardless of how inaccessible resources are, if the leaders are not willing to recommend them, they are irrelevant to their citizens which is extremely detrimental to the fight to mitigate symptoms of trauma. Logan 43
This issue was confirmed by many of the interviews conducted in the NGO offices. The ignorance of the people stems from the unwillingness of the elders to seek out other methods of treatment (Anonymous ICRC Staff Member, personal communication, February 22, 2016). It begs the question, are the chiefs really ignorant to Western medicine or is this stemming from fear of culture erosion and loss of power over their community members. The answer came from Leonard Lamwodo (a psycho-social counselor and scholar in psychology). He believes that because the chiefs are beginning to realize that their methods or recommendations are no longer providing adequate treatments, it is beginning to cause worry that they will lose their power in their community (Leonard Lamwodo, personal communication, March 4, 2016). There is also the factor that NGO’s are paying local chiefs to perform these rituals in mass ceremonies in order to incorporate cultural aspects into recovery. However, it is Mr. Lamwodo’s belief that these paychecks are motivating the chiefs to push the traditional method over the psycho-social counseling (Lamwodo, personal communication, March 4, 2016). Therefore, culture is one of the most significant challenges to helping the rural villagers find the treatment and the counseling that they need in order to heal properly. In order to combat the lack of access that some of these villagers’ experience, more staff needs to be poured into trauma counseling who are willing to move out to the field to help these people There are many socioeconomic factors that keep victim’s from taking the time to travel and more staff would also mean more focus on individualized counseling which is proven to more effective (according to the Center for Victims of Trauma) when handling cases of PTSD. Overall, having resources is a great thing but if access is not efficient, it does not help the situation with trauma counselors. The ways in which trauma is treated not only needs to be improved but there also needs to be an improvement in the way organizations go about bringing these resources to the victims of trauma.
Objective Three: Examine the effects of trauma in mental health in the family in post-conflict era The largest gap in the research that was performed previous to this is that there is a focus solely on the formerly abducted and how PTSD rates are high amongst their population. Although they are still relevant to this research, this research looks at how all types of trauma are experienced by so many other demographics. Especially when paired together into families. The Logan 44 intent of this objective is to look at the next generation after the conflict. The children of those that were directly affected by the atrocities the LRA caused. Therefore, the following findings connect the directly affected by trauma to the next generation who seem to be just as traumatized without directly being involved in the LRA conflict. Referred to during some interactions as “trickling trauma,” it is a new development in the mental health sector in post-conflict Uganda. It is the idea that men and women who were directly affected by the conflict are carrying symptoms of PTSD, depression, and anxiety and those symptoms are directly affecting their children negatively. This creates a trickle-down effect of trauma for victims that were not directly affected by the conflict. A consequence of undiagnosed trauma related disorders, husbands, wives and children are all affected by this consequence that is created by lack of resources. Unfortunately, the consequences of these effects can be gender-based violence (GBV), alcoholism, gambling, unemployment and other issues affecting the well-being of the family. With gender-based violence, this began as a direct result of the conflict. This is because as a result of trauma and atrocity, men begin to slip into depression and unmotivated states due to the many things they either experienced or lost before and during the time of encampment (Lamwodo, personal communication, April 6, 2016). Because of this change in attitude, the women of the house had to take control of the home plagued with the job of both provider and caretaker. With this shift in structure, the men of the household begin to feel inferior because they have lost the authority they once had. The inferiority then leads to aggression towards family members. Unfortunately, this leads to gender-based violence and domestic abuse (Lamwodo, personal communication, April 6, 2016). It has been noted by the ICRC that trauma in spouses is also linked to gender-based violence in the home. Therefore, their organization has stayed present in the area due to its concern that if husbands are beating their wives as a result of PTSD, their child is then affected from the trauma of watching the violence occur. As a result, the child is now mentally unstable because of the instability amongst his parents (ICRC anonymous, personal communication, February 22, 2016). Unfortunately, they are now experiencing a new form of trauma, a trauma that is not directly linked to the atrocities that occurred during the LRA conflict but rather an indirect exposure to violence through the trauma of their parents. Logan 45
Gender-based violence and domestic abuse within the home can cause psychological problems not only for the spouse but also for their children. For example, in Likodi, a woman was the daughter of another woman who had witnessed her village murdered in front of her. This woman began to act with spite and abuse towards her children. Her daughter grew up in a harsh environment in depression from her mother’s trauma. That same daughter then had her own children and began to experience extreme hatred and bitterness towards her own children and was very blameful of her husband for her mood swings. Her mood swings began to become extreme and the depression grew so deep that she one day that she tried to kill herself and her child (Kisozi, personal communication, April 20, 2016). This example shows the power of untreated trauma symptoms and how they can escalate throughout time without proper resources and help to mitigate them. This example is also unique because of the uncommon swapping of the gender violence. However, the main point is that because her mother was untreated and abused her children. Her children grew up with severe trauma and behavioral issues which would lead to the almost death of this woman’s child. This is a clear example of trickling trauma as it permeates through multiple generations. Thrive Uganda is an organization that attempts to delve into this issue of family trauma. With gender based violence especially, it aims to sensitize the communities to the issues that come from trauma in order to get recommendations for clients. They are one of the few organizations that combine individualized counseling with family counseling, economic empowerment, and education about the disorders that exist (Thrive Gulu, personal communication, April 22, 2016). GBV is a topic they focus on in order to mitigate the effects on the children that live in the household because violence in the home can cause a child to hyper- focus on the situation and begin to struggle in school (Thrive, personal communication, April 22, 2016). Akena Fred David spoke in his experience as a school teacher that the youth are growing up traumatized and are therefore turning to alcoholism, gambling, and general disrespectful behavior due to isolation (Akena Fred David, personal communication, February 20, 2016). It has also led young adults to drop out of school, causing them to not be able to function in society due to lack of formal education. They end up on the streets and spending all of their money on alcohol (Akena Fred David, personal communication, February 20, 2016). It was mentioned earlier in the findings about the suicide rates of children in rural areas. Uganda as a whole Logan 46 experiences 18.75 suicides per 100,000 people (WHO, 2012). Children will leave school and commit suicide with prior symptoms that went unnoticed by teachers in the system (David, personal communication, February 20, 2016). This issue is not one that only affects Kitgum but also Gulu. Children are exhibiting signs of troubles at home but there is no concept of how these symptoms present themselves. Mr. Lamwodo said that if they could train teachers to see the symptoms in children, then that would be a way to get to the parents of the children and counsel them through their issues (Lamwodo, April 6, 2016). Ultimately, the stress from the issues that their parents experience ultimately causes performance in school to suffer and in some cases lead to failure. If there was a way to notice the sudden decline in a child’s performance, then the symptoms can be caught before anything tragic happens to the child or anyone at home. Thrive Gulu works to sensitize the community and utilizes elders who are aware of the ways that trauma can affect a person. In this way, cases can be referred to them because suicide, to them, is an unacceptable consequences of undiagnosed trauma as it can be prevented with proper care (Thrive Gulu, personal communication, April 22, 2016). As suggested before, psychological support should be priority and Thrive prides themselves on the ability to take psychological needs first and then offer economic empowerment second. This relates back to the family because often times family members do not seek help as they are worried about wasting time and money on themselves when they have to pay their children’s school fees (Woman Awach, personal communication, April 19, 2016). Economic issues are a very common problem that comes from those that suffer from PTSD and other mental health issues. Each interview that was conducted in Abwoch and Awach in Gulu and every respondent mentioned that their symptoms impeded their ability to provide for their children (Personal Observation, April 2016). This means that the twenty people surveyed in these areas all mentioned having economic troubles which from the perspective of trauma counselors only fuels the flames of the symptoms that come from PTSD (Thrive, personal communication, April 22, 2016). Unfortunately, external issues often times impede parents to seek the help they need and it is a challenge for those that have the resources to initiate them if there is not priority in the victims to seek it out. Another issue that comes from trauma within the family is alcohol dependence. Many women in the village of Abwoch spoke of the atrocities that their husbands went through while Logan 47 being abducted, only to come home and spend what little money they made on alcohol (Abwoch focus group, personal communication, April 23, 2016). So not only is the trauma affecting the father figure but also affecting the family economically and sometimes emotionally because of stress and anxiety of how to pay for things they need. Many cases that were spoken of during this research explained that alcohol in their family also caused aggressive behavior (Abwoch focus group, personal communication, Aril 23, 2016). Therefore, indirectly, the women spoke about GBV in their homes. However, the worst part about this is that these women also have suffered great losses in their lives and experienced great tragedy during the conflict. Not only do they carry the weight of their own trauma in their mind but then their symptoms are made worse by the violence that comes from drunk family members (Abwoch focus group, personal communication, April 23, 2016). In addition to alcoholism, trauma can cause unemployment which directly affects the family in a way that affects the whole family. The symptoms of depression, anxiety, and most of the symptoms of PTSD can cause withdrawal, no motivation, and isolation which was discussed earlier in the findings. Because of this some people quit their jobs, have their employment terminated, or can no longer function in a work place environment while experiencing the flashbacks that they suffer from (Awach and Abwoch observation, April 2016). In one case, a woman suffers with extreme flashbacks and irrational behavior stemming from her trauma from her abduction. She experienced so much paranoia from being out in the open that she often would be found hiding during different parts of her job. She then began to try to work out in the field but working out in the field caused her uncomfortable flashbacks of moments where she was told to trudge through the bush with the items the LRA made her carry. This caused an inability for her to function in a normal work setting and her employment was ended. These flashbacks became so frequent that she at one moment blacked out, gathered her children, and locked them in the hut that she then preceded to set fire to. Passing out, she awoke to her family rescuing her and her kids from the fire. However, she explained that she had no control over these actions (Woman from Abwoch, personal communication, April 23, 2016). Not only does she suffer from her own symptoms, but her children are now traumatized from the actions that their mother does with no control over. This leads to a general fear instilled in children that were not there for their mother’s abduction but are rather indirectly affected from her traumatization. In this way, the conflict has now indirectly affected the next generation of Logan 48 those that should be growing up free of the atrocity that occurred during the twenty years of conflict. Even in a place like Pajong in Mucwini, where a massacre occurred involving 56 people who were killed on the main road after being gathered from their homes, World Vision was able to reach some and counsel them on their trauma. However, much more is needed because when interviewing those that had suffered, there was still immense bitterness held by members of families that lost loved ones. Their depression causes isolation and an unwillingness to aid other family members with their struggles because of the loss of their own direct family (Pajong Focus Group, April 13, 2016). The communal living that the Acholi pride themselves on usually creates a family-like atmosphere of looking out for one another. However, because of the trauma that occurred in Pajong, many people are isolated and protective of their immediate belongings (Pajong Focus Group, April 13, 2016). Even the indirect family dynamic begins to break down at the symptoms of trauma. It is a tangled web of depression, anxiety, and aggression that causes a family to now live in distress. Even those that are suffering are constantly blaming themselves, blaming others, and becoming defensive because there is a lack of understanding of what is happening to them (Kisozi, April 20, 2016). Due to the lack of identification of the trickling effects of trauma on the family, sometimes only one person is selected for treatment when it should be the entire family that comes in for group therapy separate from the individual’s therapy. This is the approach that Thrive is developing into in the next year in an attempt to begin to analyze this issue. They are the only office surveyed in this research that is attempting to create a family approach in addition to individualized therapy. In order to avoid creating a culture of traumatized people, it is crucial to begin to analyze the effect person’s tragedy is having on other people and study more than just the individual. Unless this thinking changes, people will continue to be people within households that are silently suffering from secondhand symptoms of someone who is suffering from PTSD. Unfortunately, because this thought process is not as prevalent as the immediate psychosocial support of an individual, many spouses and children suffer from the aftermath of traumatic events and their effect they have on a person’s mind.
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Objective Four: Propose ways in which trauma treatment challenges could be mitigated In a place where mental health is such a large concern to the majority of the people of the North, ten years post-conflict, there are still gaps in the resources and treatment of those that suffer from their traumatic experiences. Some recommendations have come from the respondents that were interviewed and others are made from observations that have been made during the time this topic has been researched. Leonard Lamwodo proposes that counselors should exist within the school system. If there is no money in the budget for this, then teachers should be trained in basic education of mental health among children (April 6, 2016). If there were resources for reaching out to children who are exhibiting signs of depression, anxiety, or general behavioral changes, there would be a chance to help those children improve their educational experience and receive the help they need. It would also benefit the parents to be referred to a counselor if it is their trauma that is affecting the child. He believes that families can be reached through their children and that the early signs of depression can be caught before it turns to suicide. Other suggestions have come from Thrive in the form of developing diverse group therapy sessions. If group therapy is the option that is presented to the client, then they should be afforded the opportunity to choose the proper group to be a part of, whether it be family counseling, PTSD support groups, or individualized counseling (Thrive, April 6, 2016). This is something that the organization is working towards and looks to add these options into their list of resources for traumatized peoples. This proposal is something that a lot of organizations could benefit from, instead of grouping all people into a large group of mentally ill victims, separate them out for better understanding of their symptoms and better suited treatment. From this idea of diversifying the types of therapy provided, it can be also suggested that more counselors need to be put out in the field in order to cater to these needs. If more psychology students went into field work instead going directly into the academic world, then the needs of the rural areas could be met. However, this requires more staff to be provided which the budget for a lot of organizations cannot provide. The budget for many organizations is the reason as to why they do not offer all of the services that they could. If more money were to be raised more staff could be hired which could lead to more individualized counseling. This would create a higher quality recovery process for each person. With individualized goal setting, there is a unique plan to get better where as in a Logan 50 group therapy, the personal needs of each person can sometimes be forgotten. Benard Kisozi believes that individual therapy is the direction that all organizations should strive for because of it careful consideration of individual needs and situations (Kisozi, April 20, 2016). An additional proposal can be made with the information that Benard Kisozi offered in his interview. Because some counselors are so quick to diagnose and prescribe, it is of the opinion of the researcher that medication should be a final resort for treating trauma related disorders. If medication is going to be prescribed, it should be done in a way in which instructions are clearly given and follow-up meetings are set in order to have medicine management accountability. This would avoid the issue of prescribing too much medicine to where someone could overdose and meetings to check up on medicine that is prescribed can better control the schedule in which the medicine is being consumed and how it is affecting the victim. If the medicine is not having the desired impact, more frequent follow up meetings can create a customized plan on how to combat the issues that they want to mitigate for themselves. That being said, an increase in follow ups for counseling is needed in general, realizing that this is at the hands of a budget, it is still believed to be the most important way to improve services that can be provided to those that need them. In addition to the increase in individualized counseling sessions, it is proposed that the focus of trauma treatment slowly step away from economic empowerment as a first response. Economic empowerment certainly mitigates external stress but the mental health resources, from the researcher’s observations, have walked away from psychological counseling as a first response to a victim’s symptoms. Psychological responses are incredibly important to the victim as it takes care to improve their internal stresses which inevitably affect their external stressors. An inside-out approach to the issues that plagued trauma victims can create a long lasting approach to healing instead of only covering up the internal feelings with the possibility of making more money for themselves. This is means that they can make attempts at living a more quality life both mentally and physically.
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Chapter Five: Conclusions In conclusion of the research on trauma, its treatment, and its effects on the family unit, it can be said that the study of the mental health situation in post-conflict Uganda is in no way a topic that can be researched in full in the time that this research took place. There is a lot of improvement and development that still needs to take place to take care of those that are still suffering from the traumatic experiences that happened ten years ago. On the topic of diagnosis and the way that trauma presents itself in mental health, it is extremely important to diagnose the issues correctly. It is also important to understand the ways in which it shows up in different demographics of people to better evaluate the situation and create a plan of recovery for the victim. When doctors, teachers, and community members are properly trained in the ways that trauma can affect someone’s mental stability, there is a better chance of recovery and healing. It can also prevent horrible side effects that affect the victim and the community in ways like suicide and irrational, aggressive behavior that can harm those around them. Therefore, one of the main factors in the way that trauma effects families of northern Uganda is the misunderstanding of symptoms and how they can be treated. The treatment of these symptoms has many issues within its realm. However, the two main ways that are utilized in northern Uganda is psychological counseling and psychosocial support. Out of the two, the focus should be on psychological counseling as it handles the internal stressors of a person that are ultimately affecting the external stressors that they are experiencing. This way their trauma is not linked to their socioeconomic stress and they can focus on one thing at a time and then finally move into bettering their external situation. Individualized care is key in this issue, for better diagnosis and for an individual plan on how to recover for themselves aside from their responsibilities at home. This can mean more efficient emission of drugs and a better experience with the healing process. Individuals are not the only group of people affected by the trauma that raged through northern Uganda. Families are affected through the trickle down of traumatic experiences that are affecting the family’s inability to function as a unit. It was found that the adults in the family can affect the mental wellness of the child in ways that create stress and depression in their children. It can lead to things such as depression, GBV, alcoholism, and unemployment which all effect each member of the family separately. However, with the lack of focus on the family as a Logan 52 whole, many people suffer without support. Therefore, the focus should be about a wholesome approach if the symptoms of the traumatized are being pressed upon their family members. In general, there are major improvements that need to be made to the way in which mental health is treated. If not, there is a dangerous path forming towards a new generation of traumatized Ugandans. Those who did not live during the conflict do not deserve to suffer in the same way that those who lived during that time nor do the people who lived during that time deserve to suffer for this long. More research will need to be done and more initiatives need to be established in an effort to improve a field of post-conflict effects that does not garner attention. It is the hope of the researcher that these findings contribute to the improvement of this system in a continuation of support for better trauma treatment and recovery in an effort to truly give every traumatized victim the chance to heal from the atrocities of the LRA conflict.
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References
Allen, T. (2015). Life Beyond the Bubbles: Cognitive Dissonance and Humanitarian Impunity in Northern Uganda. In Medical Humanitarianism (pp. 96-118). University of Pennsylvania Press.
Annan, J. (2011). Civil War, Reintegration, and Gender in Northern Uganda. Journal of Conflict Resolution, 1-32.
Baingana, F., & Mangen, P. (2011). Scaling up of mental health and trauma support among war affected communities in Northern Uganda: Lessons Learned. Intervention, 9(3), 291-303.
BBC. (2015, February 21). Breaking the stigma around mental illness in Uganda. BBC.
Bisson, J. (2015). Post-Traumatic Stress Disorder. The Biological Medical Journal, (351). https://dx.doi.org/10.1136/bmj.h6161 The Enough Project. (2012). History of the LRA Conflict in Northern Uganda. Retrieved from The Enough Project website: http://www.enoughproject.org/files/publications
Insight on Conflict. (2014). Uganda: Conflict Timeline. Retrieved from Insight on Conflict website: http://www.insightonconflict.org
Invisible Children. (2014). History of the Conflict. Retrieved from Invisible Children website: http://www.invisiblechildren.com
Muldoon, K. (2014). After abduction: exploring access to reintegration programs and mental health status among young female abductees in Northern Uganda. Conflict and Health. http://dx.doi.org/10.1186/1752-1505-8-5
National Institute of Mental Health. (n.d.). [Symptoms of PTSD]. Retrieved April, 2016, from National Institute of Mental Health website: https://www.nimh.nih.gov/index.shtml Logan 54
Nakimuli-Mpungu, E. (2013). The impact of group counseling on depression, post-traumatic stress and function outcomes: A prospective comparison study in the Peter C. Alderman trauma clinics in northern Uganda. Journal of Affective Disorders, 151(1), 78-84.
Olak, K., Ovuga, E., Stochl, J., & Abott, R. (2013). Postwar environment and long-term mental health problems in former child soldiers in Northern Uganda: the WAYS study. Epidemical Community Health, 68, 425-430.
Ovuga, E., & Larroque, C. (2012). Post Traumatic Stress Disorder: A Northern Uganda Clinical Perspective. Post Traumatic Stress Disorders in a Global Context, 183-208.
Ovuga, E., Olak, K., Jones, P., & Abbott, R. (2013). Cohort Profile: Mental Health following extreme trauma in a northern Ugandan cohort of war-affected Youth Study (The WAYS Study). Springer Open Journal, 1-11.
United Nations High Commission for Refugees. (2012, January 6). UNHCR closes chapter on Uganda's internally displaced people. Retrieved from UNHCR website: http://www.unhcr.org/4f06e2a79.html
World Health Organization. (2006). WHO-AIMS Mental Health Report Uganda. World Health Organization.
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Appendices i. LRA War Timeline 1962: Uganda gained independence from its British colonial rulers (Insight on Conflict, 2014). Significance: The British had caused ethnic divides between the north and the south of Uganda. This created a militarized reputation for the North, creating tension between the north that was recruited for war in World War I and II and the south which was educated and more economically well-off. 1966: Milton Obote becomes President of Uganda under the UPC. Significance: Buganda was dissatisfied that they were taken out of power, Obote’s life became in danger and it was the true showing of the North/South divide by creating boiling tribal conflict. 1976: Idi Amin declares himself President for life through a military coup. 1976-1979: Tribal killings began to occur and the Acholi people were targeted by Amin because he believed that if he killed them then they could not rise up against his administration. Significance: This sparked an uprising to be planned in Tanzania for those that fled persecution, Amin is then toppled by this rebel movement. 1980-1984: Obote wins presidency in a rigged election. Significance: The ethnic killings shifted between the Acholi, West Nile, and the Langi. 1985: A military coup is planned and is successful, taking Obote out of power and replacing him with General Tito Okello. Significance: Lootings and celebrations took place in Gulu and an air of anger and revenge that was fueled from the Amin administration. 1986: Yoweri Museveni, leader of the National Resistance Army (NRA), overthrows President Milton Obote and makes himself president of Uganda. In order to root out “enemies” he begins to target the Northern population of Acholi people (Enough Project, 2012). Logan 56
At the same time, a woman named Alice Lakwena (An Acholi from the North) creates the rebel group the Holy Spirit Mobile Forces, a group she believes to be an order from Christian “spirits” to create. Significance: Museveni used the chaos to take power and the North suffered from it and this caused the creation of the civil rebel groups. There was a belief that Museveni wanted to eliminate the North. 1888: Alice Lakwena is defeated and flees to Kenya. Joseph Kony (a cousin of Alice Lakwena) recruits her army and creates the Lord’s Resistance Army. 1993: The Sudanese government begins to provide direct support to the LRA. In addition, the LRA begins to support Khartoum’s war against the Sudan People’s Liberation Army in southern Sudan. Significance: This was one of the many issues that led to the perpetuation of the war. The Ugandan government was supporting the SPLA which was against the government of Sudan and so therefore, Sudan hosted the LRA in spite of that factor. 1994: Museveni was supposed to sign peace negotiations but instead he addressed a rally and threatened the LRA with an ultimatum of seven days to come out of the bush. Elders were killed by the LRA during the peace talks. Significance: There is a theory that this event occurred because they wanted to elongate the conflict because the Fourth Division (UPDF Soldiers in the North) wanted to be paid and therefore did not want the conflict to end. 1996: Museveni wins presidential election with 75 percent of the vote (Insight on Conflict, 2014). The Ugandan government forced civilians out of their homes and into camps for Internally Displace Persons (IDP) (Invisible Children, 2014). 2002: Operation “Iron Fist” is launched by Museveni which was aimed at wiping out the LRA. Significance: This only agitated the LRA and caused more atrocities to occur at an expedited rate. They started abducting more children and terrorizing more villages. 2004: The government of Uganda and the LRA hold first face-to-face peace talks. Logan 57
They are not successful (Enough Project, 2012). 2005: Presidential term limits are abolished. ICC issues arrest warrants for five LRA commanders and Joseph Kony. International Criminal Court of Justice find Uganda guilty of violating the sovereignty of DRC and orders them to pay compensation (Insight on Conflict, 2014). Significance: It is believed that the arrest warrants stunted peace talks because Joseph Kony did not want to be arrested and prosecuted for what he did. Therefore, it deterred peace talks from successfully being signed. 2006: Museveni wins presidential election. Juba Peace Talks are hosted by Juba Sudan. LRA declares a ceasefire and more peace talks are held throughout August and the rest of the year. However, the LRA made camp in the north of the DRC continuing to abduct children and raid villages. Significance: Joseph Kony continuously postponed signing the final document and this would eventually lead to never signing the final peace document created by the negotiations (Invisible Children, 2014). 2008: LRA and the government sign permanent ceasefire in February but Joseph Kony fails to attend the signing of a peace agreement in November. Significance: Joseph Kony continues to spread into the neighboring countries, abducting children and causing atrocities to occur outside of Uganda.
Logan 58 ii. Data Collections Tools: Question Guide Question Guide: 1. (For Organizations) What is the main mission of your organization? 2. How does this further the cause of mitigating trauma and mental health disorders? 3. In your experience in this organization, how have you seen mental health affect the community specifically in men, women, and children? 4. Do you believe that there are adequate resources available for those suffering from PTSD that were not the formerly abducted population? 5. How efficient are the tactics that are in place and what are the success rates that you see in your programs? 6. (For Victims) What was our experience with the conflict? 7. Have you experienced bad dreams, flashbacks, or tensions related to your experience with the conflict? 8. Have you ever felt trauma from your experiences with the conflict? 9. If so, have you ever sought treatment? 10. If so, have you ever been educated on the types of programs available to you? 11. How has your experience affected your family? Do you see signs of trauma amongst your family members? 12. If so, how does that effect your home life?
Logan 59 iii. Uganda National Council for Science and Technology Research Permit
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